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Pollman, Claire L. NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Claire L. Pollman Female Date of Death Age If Veteran of U.S.Armed Forces, 12/13/2019 76 Years War or Dates H Place of Death Hospital,Institution or WCity,Town or Village Indian Lake Town Street Address 225 Adirondack Lake Road,Indian Lake Town,New York 12842 p Manner of Death ©Natural Cause Accident Homicide ❑Suicide Undetermined Pending W Circumstances Investigation U W Medical Certifier Name Title Ryan Donnelly DO Address 9 Carey Road,Queensbury Town, New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Indian Lake ----T2053 9 ❑Burial Date Cemetery,Crematory or Facility Name 12/16/2019 Pine View Crematory Entombment Address Cremation Queensbury Town, New York Donation z Removal Date Place Removed and/or and/or Held F— Hold Address U) O 9- Date Point of U) D Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Miller Funeral Home 01199 Address 6357 Nys Rte#30, Indian Lake, New York 12842 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above Address W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/16/2019 Registrar of Vital Statistics JilieA Ows-7(ElefrC4dlyS9W (signature) District Number 2053 Place Indian Lake, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H W Date of Disposition ►2/IV 111 Place of Disposition �•� (,JtDn.— LU (address) W U)Q (section) (lot num r (grave number) — C3Name of Sexton or Person in Charge of Premises r'j ``"please print) Z W Signature Title DO H-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 013154 Receipt Human remains of : _ delivered on , 20 r /'r ' r-r-,✓jam 'r.a''S.,- Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#